This document defines acute rheumatic fever as an indirect complication of group A streptococcal pharyngitis that primarily affects the heart, central nervous system, joints, and skin. It discusses the major manifestations of acute rheumatic fever such as carditis, migratory polyarthritis, Sydenham's chorea, erythema marginatum, and subcutaneous nodules. The modified Jones criteria for diagnosing acute rheumatic fever requires two major manifestations or one major and two minor manifestations along with evidence of a prior streptococcal infection. Treatment involves antibiotics, salicylates or steroids depending on symptoms, and long-term antibiotic prophylaxis to prevent recurrences.

1. Acute rheumatic fever
5/10/2023 By Tomas 1

2. objective
At the end of the session
- Define rheumatic fever
- Explain the manifestation of rheumatic
fever
- discuss the management of rheumatic
fever
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3. Acute Rheumatic Fever
 Indirect (non-suppurative)
complication of group A beta-hemolytic
streptococcal pharyngitis
 Delayed immune response
 Primarily affects the heart, CNS, joints
and the skin
 Carditis is the only long-term
complication
 All the others resolve
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4. Acute Rheumatic …
 Acute rheumatic fever is the most
common cause of acquired heart
disease in children living in sub-
Saharan Africa and other 3rd world
countries.
 Acute rheumatic fever is preventable
 Prompt and proper treatment of
streptococcal pharyngitis can
eliminate the risk for acute rheumatic
fever.
 Peak age for ARF is 5 – 15 years (rare
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5. Risk factors
Poverty, overcrowding and conditions
facilitating spread of gr.A streptococcal
pharyngitis.
Magnitude of the immune response to
the antecedent streptococcal pharyngitis.
Persistence of the organism during
convalescence.
Rheumatogenicity of gr.A strept strains.
Previous attack of rheumatic fever
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6. Major manifestations
1. Carditis (in 50 – 60% of patients)
Pancarditis (myocardium, endocardium and
pericardium).
The most specific manifestation of rheumatic
fever.
Cardiac murmur – most important manifestation.
Mitral and Aortic valvulitis and involvement of the
chordae of the mitral valve – most characteristic.
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7. Major manifestations
Mitral regurgitation – hallmark of
rheumatic carditis.
Involvement of the right side valves
(TV & PV) – less common.
2. Migratory polyarthritis (in about 75%
):
Most common major manifestation
but least specific.
Almost always asymmetrical and
migratory.
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8. Major manifestations
Larger joints (knees, ankles, elbows,
wrists).
Swelling, severe pain, redness, heat,
limitation and tenderness.
No permanent joint deformity.
Untreated – lasts 2 to 3weeks.
Dramatic response to salicylates
- hallmark
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9. Major manifestations
3. Sydenham's Chorea (involvement of
Basal ganglia & caudate nucleus)
 In about 20% of patients with RF.
 Delayed manifestation – usually 3mo
or longer.
 Purposeless and involuntary
movements, muscle incoordination,
weakness and emotional liability.
 May disappear with sleep.
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10. Major manifestations
4. Erythema marginatum:
In < 5% of cases.
Evanescent, erythematous, macular
nonpruritic rash with pale centers and
rounded or serpinginous margins.
Mostly trunk and proximal
extremities.
May be induced by application of
heat.
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11. Major manifestations
5. Subcutaneous nodules
In less than 3% of patients with RF.
Firm, painless, freely movable nodules (0.5 – 2cm in size).
Most often seen in patients with carditis.
Usually located over the extensor surfaces of the joints
(elbows, knees and wrists), in the occipital portion of the scalp,
or over the spinous processes.
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12. Diagnosis of acute rheumatic
fever
Modified Jones Criteria:
Major –
Carditis
Migratory polyarthritis
Sydenham’s chorea
Erythema marginatum
Subcutaneous nodules
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13. Modified Jones …
Minor criteria
Clinical findings
 Arthralgia
 Fever
Laboratory findings
 Elevated acute phase reactants (ESR,
CRP).
 Prolonged PR interval.
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14. Modified Jones …
Supporting evidence for antecedent
streptococcal pharyngitis:
 Positive throat culture or rapid
streptococcal antigen test.
 Elevated or rising streptococcal
antibody titer.
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15. Modified Jones …
Diagnosis made with:
2 major criteria or 1 major and 2
minor
+
Supporting evidence for antecedent
streptococcal pharyngitis (mandatory)
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16. Modified Jones …
Exceptions (strict adherence to Jones
criteria not needed):
1. Sydenham’s Chorea
2. Indolent Carditis
3. Rheumatic Fever recurrence
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17. Treatment of acute rheumatic
fever
General
Place on bed rest and monitor closely
for evidence of carditis.
Antibiotic treatment for 10 days with
oral penicillin or erythromycin or a
single IM dose of Benz. Penicillin.
Long-term antibiotic prophylaxis.
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18. Treatment of acute rheumatic
fever
Anti – rheumatic therapy:
Withheld anti-inflammatory treatment till full blown picture
of RF appears.
Pain relief – achieved by acetaminophen.
Migratory polyarthritis and carditis with out Cardiomegaly or
CHF → ASA 100mg/kg/24hr divided into 4 doses po for 3 – 5
days, then 75mg/kg/24hr for 4weeks.
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19. Treatment of acute rheumatic
fever
Carditis with cardiomegaly or CHF →
Prednisone 2mg/kg/24hr divided into
4 doses po for 2 – 3weeks. While
tapering prednisone start ASA
75mg/kg/24hr in 4 divided doses for
6weeks.
Supportive treatment.
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20.  If Sydenham's chorea - Sedatives
phenobarbital (16-32 mg every 6-8 hr
PO) is the drug of choice. If
phenobarbital is ineffective, then
haloperidol (0.01-0.03 mg/kg/24 hr
divided bid PO) or chlorpromazine
(0.5 mg/kg every 4-6 hr PO) should be
initiated
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21. Prevention
I. Primary Prevention (prompt and proper
treatment of gr. A streptococcal pharyngitis)
after 9 days of pharyngitis episode.
Benz. Penicillin
weight ≤ 27kg→ 600,000IU IM stat.
weight > 27kg→ 1,200,000IU IM stat.
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22. Prevention
II. Secondary prevention (prevention of
recurrence).
Benz. Penicillin 1.2M IU IM every 3 –
4 weeks.
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23. THANK YOU!
5/10/2023 By Tomas 23